Can (myofascial) trigger points cause shoulder pain
(myofascial) trigger points are a very large cause of shoulder pain. They have been found to be extremely common in sufferers of... Read Article
Massage and trigger point therapy for shoulder pain, with self help options
Muscular problems including trigger points have been shown to be a major cause of shoulder pain, with massage and trigger point therapy giving great relief (1–8). Looking at which muscles cause the problems a team of researchers found that (myofascial) trigger points in 17 different muscles contribute to shoulder pain (1,9). These problems were so common that of the 72 sore shoulders they examined 68 (about 95%) had these problems in at least one muscle, with over half having them in at least 10 muscles.
There can be other causes of shoulder pain so we encourage sufferers to get professional advice. However, with about 95% of sore shoulders having at least some muscular issues, massage or trigger point therapy for the 17 muscles the researchers found should be part of the management plan.
In this article I’ll discuss your general massage and trigger point therapy options, then go over specific therapies for the 17 muscles involved. To properly remedy your problem these need to be repeated many times. This can get very expensive if done professionally, so where possible self massage and trigger point therapies will be shown.
CONTENTS
Other causes of shoulder pain
The muscular problems researchers found
Massage and trigger point therapies for these muscles
Appendix: the "medical" causes of shoulder pain
Professionals
References
Graeme’s comments
The research shows trigger points in the muscles are involved about 95% of the time, but there are other causes that need to be looked at as well. For this reason I ask that you get some professional advice. For general information I’ll first go over three other common causes a professional may consider, then show you the 17 muscles and the therapies you can use.
Other causes of shoulder pain
Postural issues
As discussed in the article The real reason shoulder impingement keeps coming back postural problems are a big cause of shoulder pain. Simply, postural changes alter the pull on the shoulder muscles and the mechanics of the shoulder joints. Obviously to remedy shoulder pain these issues need to be fixed.
Impingement syndromes
Impingement syndromes are where tissues around the shoulder joint get pinched. This condition is commonly diagnosed, but as discussed in The real reason shoulder impingement keeps coming back it is usually secondary to postural changes and/or abnormalities such as trigger points in the muscles altering the mechanics of the joints. Too often drugs or generic exercises are prescribed, oblivious to the cause. Instead the posture and muscular problems should be addressed, which will go a long way towards fixing the problem.
Other medical conditions
There are a host of other medical conditions that can contribute to shoulder pain. I’ll put the causes listed a medical journal article Clinical evaluation of nonarthritic shoulder pain: diagnosis and treatment (10) in an appendix. It is worth noting that the two main scientifically proven causes postural issues and trigger points in muscles are not mentioned. Practically every source of information for your doctor relies on drug company funding so he or she never gets to hear about a lot of things. Therefore the muscles and postures tend to be not diagnosed and the other conditions (which may be incidental) are over diagnosed.
The muscular problems the researchers found
In this section I’ll quickly discuss:
- what trigger points are
- the 17 muscles that are involved
- how common trigger points are in each, and
- how these trigger points cause shoulder pain.
What are trigger points
Trigger points are those tender lumps in your muscles that refer pain when therapists press on them. For more information please see our article Trigger point basics, but in summary they start as small lumps then gradually develop over time and can eventually start shooting pain. Before they start shooting pain you only know they are there when they are pressed upon and are called LATENT trigger points. When they start shooting pain without needing to be pressed upon they are called ACTIVE trigger points. They are the same thing so the terms are largely academic, but I mention this because the researchers use the terms in some of the information I’ll share.
The muscles and their trigger points
The following chart from (1) shows the 17 muscles and the number of those muscles (out of 72) that had trigger points. Looking at the chart, for Infraspinatus (back of the shoulder blade) we see that nearly 60 out of 72 had trigger points. On the other end of the scale we see that about 20 triceps and 20 scalene muscles had trigger points, but this is still about 30 %.
How these muscle cause pain.
We discuss this in detail in our article Can trigger points cause shoulder pain but in summary they can either:
- refer pain directly, or
- cause the mechanics of the shoulder joint to become abnormal.
This diagram shows how trigger points in one of the muscles can refer pain to your shoulder.
Massage and trigger point therapy for these muscles
You now have a list of the 17 muscles likely to be causing your shoulder pain. Any properly qualified therapist should be able to examine these and apply therapy. We certainly encourage you to get some professional advice. However, when the researchers used trigger point therapy it relieved shoulder pain but as this chart shows they found that after 12 sessions of very effective trigger point therapy 2/3 of the trigger points were still there.
In order to rid your problem you will need a lot more treatments, which would become very expensive, so in the next section I’ll show you how to examine muscles for trigger points then three effective massage/trigger point therapies you can do yourself. The three effective self therapies are:
- basic self massage
- “Thai” home trigger point therapy, and
- vibration massage (recommended)
In next section I’ll go over how to do each of these, then in the following section apply these to the individual muscles.
Trigger point examination
It is best to have a professional show you how to examine for trigger points so you learn the correct techniques and can be sure that what you find is a trigger point. However the basic examination technique is very simple. You start by using flat fingers and moderate pressure as shown to examine your muscles for tight or tender areas. If you find a tight or tender area use one or two fingers to examine deeper, looking for tight bands of muscle. Along these tight bands of muscle you may find a tender harder part (lump) that may shoot pain when it is pressed upon. These lumps are likely trigger points.
Self therapy techniques
Self therapy technique one: basic massage
I’ve demonstrated this technique in this video and on my forearm muscles here because it is easy to see. Imagine your muscle is like an old sponge and you are squeezing out the gunk. Apply pressure with your thumb or something else appropriate and slowly move along the muscle.
- Massage like this must be done towards your heart because your lymphatic (drainage) vessels and veins have one way valves. Massaging the other way would be trying to force fluids the wrong way through these one way valves.
- Work systematically to cover all the muscle
- Repeat the process using gradually more pressure to penetrate deeper.
Trigger point therapy variation
This basic massage procedure can be easily modified to turn it into a very effective trigger point therapy. All you need to do is when you get to a tight spot/ trigger point stop and hold the pressure for 5-10 seconds before slowly moving on.
Self therapy technique two: “Thai” self trigger point therapy
Professional therapists use various techniques based upon applying pressure direct to the trigger point. There are a lot of people advising to do this at home with balls and rollers. As I discuss in Do foam rollers work I have grave reservations about these. In practice as a chiropractor I’ve seen way to many people hurt themselves using these and not a lot of benefits.
On the other hand there is a traditional Thai home therapy technique that appears to be very safe and was shown to be very effective in a trial treating upper back pain (11) . It uses a special tool with a long handle to apply moderate pressure to relaxed muscles. Each day each trigger point was given five applications of this moderate pressure for five seconds each. The big differences between this technique and foam roller/ balls are:
- you are not getting into difficult positions and the muscles you are treating can be relaxed,
- it is much easier to control the pressure, and
- rather than more painful and prolonged pressure the Thai technique uses multiple short duration applications of moderate pressure.
The trial of this therapy used a tool called a wilai stick (pictured), but there are many similar tools available.
Self therapy three: home trigger point therapy using vibration massage (our recommendation)
Vibration massage is widely used by professionals to treat trigger points. It is done by simply placing the vibration massager over the trigger point allowing the vibrations to penetrate and have their effect. Because it does not require penetrating pressure it is relatively safe, and because no special skills are required it is far easier to self apply.
You can get professional results from self therapy
Self applied manual massage is often no where as effective as professional therapy because manual therapies rely on skilled application and it can be difficult to get into some positions. On the other hand a vibration massager just sits on the surface and does the work. As as long as it is applied in the right place self applied vibration massage can be as effective as professionally applied vibration.
Why vibration massage works
As shown in this diagram the key parts of a trigger point are muscle spasm, muscle tightness, restricted blood flow, and a build up of toxic wastes. Vibrations have been shown to help all of these. For more information please see our guide The scientifically proven effects of vibration massage- with clinical applications.
How to use vibration massage
Using vibration massage is extra-ordinarily easy. We ask you to check our our instructions for the fine points and precautions, but basically all you need to do is place the vibration massager on the muscle over the trigger point and let the vibrations penetrate for 30-60 seconds. This can easily be repeated every day. Please note that you need a proper effective vibration massager. As discussed in our article Should I get a massage gun or a vibration massager most of the common massage guns and percussion massagers will be ineffective.
Applying therapy to individual muscles
The muscles at the back of your shoulder blade
- infraspinatus
- teres minor
- teres major
As the diagram shows these three muscles are at the back of your shoulder blade. The scientific study (and 27+ years of chiropractic practice) show that these are the most common causes of shoulder pain.
Self massage
These muscles are very hard to reach for self massage.
Thai home therapy
As the diagram below shows it is easy to wrap your fingers around and apply moderate pressure to any trigger points found.
Vibration massage
It is best to massage these while lying on your opposite side, rolling slighly forward. Doing this the massager sits on a horizontal surface. Your arm is towards your head exposing the muscles.
Upper trapezius muscle
Self massage
You can reach this muscle easily an use the pads of your fingers to do the massage
Thai home therapy
As this diagram shows it is easy to use your fingers to apply moderate pressure
Vibration massage
The important thing here is to hold the massager with the opposite side hand. This makes sure the muscle you are massaging is relaxed.
Deltoid muscles
As the diagram shows these muscles wrap around the outside of your shoulder. It is divided into three parts: Anterior (front), middle and posterior (back).
Self massage
This muscle can be massaged by reaching across with the opposite hand and using the flats of your fingers.
Thai self massage
It is easy to apply moderate pressure to trigger points using the same technique.
Vibration massage
This can be done sitting, or lying down as in the picture below.
Supraspinatus muscle
The supraspinatus muscle sits in a groove at the top of your shoulder blade. It sits directly below part of the upper trapezius muscle.
Self massage
This can be done using the tips of your fingers similar to the way pictured in the trigger point therapy. However, as the muscle is deep you need strong fingers.
Thai self massage
Use the tips of your fingers as shown. The muscle is deep.
Vibration massage
It is far easier to let the vibrations penetrate as shown.
Middle and lower trapezius
Self massage
These muscles are at the back where you cannot easily reach.
Thai self massage
These muscles can be easily reached using a tool like previously discussed.
Vibration massage
It is easy to apply vibration to these muscle using a vibration massager. Note that because of their lack of a proper handle you won't be able to reach these properly with a massage gun.
Subscapularis
This muscle sits underneath your shoulder blade between your shoulder blade and rib cage. You cannot easily get at it, but you can get at part if you pull your shoulder blade outwards.
Self massage
This muscle is too hard to get at for self massage.
Thai self massage
You can get at the outside of this muscle with your thumb as shown.
Vibration massage
This is by far the easiest and most effective. Note that to get access to this difficult part I've used the smaller head. Also, because it is the vibrations that penetrate it can effect the muscle far further behind the shoulder blade.
Pectoralis major muscle
Self massage
This muscle is at the front of your chest so is easy to reach and self massage.
Thai self massage
As shown in the picture this muscle is very easy to access for self trigger point therapy.
Vibration massage
Again, a very easy muscle to access
Pectoralis minor muscle
This muscle is underneath part of the pectoralis major muscle. It is very important because it sits directly over the major nerves and blood vessels that go down your arm. If it is tight it can cause "pectoralis minor syndrome" which is where the nerves to your arm are irritated and blood circulation restricted.
Self massage
This muscle is at the front of your chest so is easy to reach and self massage.
Thai self massage
As shown in the picture this muscle is very easy to access for self trigger point therapy.
Vibration massage
Again, a very easy muscle to access.
Biceps and triceps muscles
Self massage
These muscles are at the front and back of your upper arm so are easy to reach and self massage.
Thai self massage
As shown in the pictures these muscles are very easy to access for self trigger point therapy.
Vibration massage
Again, a very easy muscles to access
Scalene muscles
The scalene muscles run along side some major nerves and blood vessels, plus there are sharp pointed parts of your spine directly beneath. For safety reasons don't touch this muscle unless given specific instructions by your professional.
Appendix: "Medical" causes of shoulder pain
The causes of shoulder pain according to a medical journal (10). Note that the major scientifically proven causes posture and trigger points are omitted. It's great for drug companies, but not for the public.
Table 1. Potential causes of nonarthritic shoulder pain.
- Rotator cuff pathology (tendonitis, tears)
- Bursitis
- Impingement
- Acromioclavicular pathology (sprains, instability)
- Labral tears
- Long-head biceps brachii pathology
- Instability
- Adhesive capsulitis/stiff shoulder
- Scapular dyskinesis
- Fracture
- Cervical radiculopathy
Professionals
DrGraeme massagers were originally built by Dr Graeme for use in his clinic, and to prescribe to his patients for additional self use at home. Now these are used by colleagues and other professionals for similar purposes. If you are a professional and wish to know more about this therapy, or possibly get a sample massager to trial please check out our practitioner page.
References
- Bron C, De Gast A, Dommerholt J, Stegenga B, Wensing M, Oostendorp RAB. Treatment of myofascial trigger points in patients with chronic shoulder pain: A randomized, controlled trial. BMC Med. 2011;9.
- Sergienko S, Kalichman L. Myofascial origin of shoulder pain: A literature review. J Bodyw Mov Ther . 2015;19(1):91–101.
- Senbursa G, Baltacı G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: A prospective, randomized clinical trial. Knee Surgery, Sport Traumatol Arthrosc. 2007;15(7):915–21.
- Yemul SR. COMPARISON OF SUPERVISED EXERCISE WITH AND WITHOUT MANUAL PHYSICAL THERAPY FOR PATIENTS WITH SHOULDER IMPINGEMENT SYNDROME. J Cur Res Rev . 2013;05(05):5.
- Van Den Dolder PA, Roberts DL. A trial into the effectiveness of soft tissue massage in the treatment of shoulder pain. Aust J Physiother . 2003;49(3):183–8.
- Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;
- Van Den Dolder PA, Ferreira PH, Refshauge KM. Effectiveness of soft tissue massage and exercise for the treatment of non-specific shoulder pain: A systematic review with meta-analysis. Br J Sports Med. 2014;48(16):1216–26.
- Hains G, Descarreaux M, Hains F. Chronic Shoulder Pain of Myofascial Origin: A Randomized Clinical Trial Using Ischemic Compression Therapy. J Manipulative Physiol Ther 2010;33(5):362–9.
- Bron C. High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. BMC Musculoskelet Disord. 2011;12.
- Holmes RE, Barfield WR, Woolf SK. Clinical evaluation of nonarthritic shoulder pain: Diagnosis and treatment. Phys Sportsmed. 2015;43(3):262–8.
- Wamontree P, Kanchanakhan N, Eungpinichpong W, Jeensawek A. Effects of traditional Thai self-massage using a Wilai massage stickTM versus ibuprofen in patients with upper back pain associated with myofascial trigger points: a randomized controlled trial. J Phys Ther Sci. 2015;27(11):3493–7.
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About Dr Graeme
Several years ago Dr Graeme, a Chiropractor practicing in Victoria, Australia was looking for a serious hand held massager his patients could use at home to get the extra quality massage they needed. The ones he found in the shops and on-line for home use looked nice but were not serious, and... read more
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